Local multidisciplinary teams

1.1.1.

Local multidisciplinary teams (MDTs) for women with primary stress urinary incontinence, overactive bladder or primary prolapse should:

• review the proposed treatment for all women offered invasive procedures for primary stress urinary incontinence, overactive bladder or primary prolapse
• review the proposed management for women with primary stress urinary incontinence, overactive bladder or primary prolapse if input from a wider range of healthcare professionals is needed
• work within an established clinical network that has access to a regional MDT^[1]. [2019]

1.1.2.

Local MDTs for women with primary stress urinary incontinence, overactive bladder or primary prolapse should include:

• 2 consultants with expertise in managing urinary incontinence in women and/or pelvic organ prolapse
• a urogynaecology, urology or continence specialist nurse
• a pelvic floor specialist physiotherapist

  and may also include:

• a member of the care of the elderly team
• an occupational therapist
• a colorectal surgeon. [2019]

1.1.3.

Members of the local MDT (listed in recommendation 1.1.2) should attend all local MDT meetings. [2019]

Regional multidisciplinary teams

1.1.4.

Regional MDTs that deal with complex pelvic floor dysfunction and mesh-related problems should review the proposed treatment for women if:

• they are having repeat continence surgery
• they are having repeat, same-site prolapse surgery
• their preferred treatment option is not available in the referring hospital
• they have coexisting bowel problems that may need additional colorectal intervention
• vaginal mesh for prolapse is a treatment option for them
• they have mesh complications or unexplained symptoms after mesh surgery for urinary incontinence or prolapse
• they are considering surgery and may wish to have children in the future. [2019]

1.1.5.

Regional MDTs that deal with complex pelvic floor dysfunction and mesh-related problems should include:

• a subspecialist in urogynaecology
• a urologist with expertise in female urology
• a urogynaecology, urology or continence specialist nurse
• a pelvic floor specialist physiotherapist
• a radiologist with expertise in pelvic floor imaging
• a colorectal surgeon with expertise in pelvic floor problems
• a pain specialist with expertise in managing pelvic pain

  and may also include:

• a healthcare professional trained in bowel biofeedback and trans-anal irrigation
• a clinical psychologist
• a member of the care of the elderly team
• an occupational therapist
• a surgeon skilled at operating in the obturator region
• a plastic surgeon. [2019]

1.1.6.

Regional MDTs that deal with complex pelvic floor dysfunction and mesh-related problems should have ready access to the following services:

• psychology
• psychosexual counselling
• chronic pain management
• bowel symptom management
• neurology. [2019]

1.1.7.

Members of the regional MDT (listed in recommendation 1.1.5) should attend regional MDT meetings when their specific expertise is needed. [2019]

History taking and physical examination

1.3.1.

At the initial clinical assessment, categorise the woman’s urinary incontinence as stress urinary incontinence, mixed urinary incontinence or urgency urinary incontinence/overactive bladder. Start initial treatment on this basis. In mixed urinary incontinence, direct treatment towards the predominant symptom. [2006]

1.3.2.

If stress incontinence is the predominant symptom in mixed urinary incontinence, discuss with the woman the benefit of non-surgical management and medicines for overactive bladder before offering surgery. [2013, amended 2019]

1.3.3.

During the clinical assessment seek to identify relevant predisposing and precipitating factors and other diagnoses that may require referral for additional investigation and treatment. [2006]

Assessing pelvic flfloor muscles

1.3.4.

Undertake routine digital assessment to confirm pelvic floor muscle contraction before the use of supervised pelvic floor muscle training for the treatment of urinary incontinence. [2006, amended 2013]

Urine testing

1.3.5.

Undertake a urine dipstick test in all women presenting with urinary incontinence to detect the presence of blood, glucose, protein, leucocytes and nitrites in the urine. [2006]

1.3.6.

If women have symptoms of urinary tract infection (UTI) and their urine tests positive for both leucocytes and nitrites, send a midstream urine specimen for culture and analysis of antibiotic sensitivities. Prescribe an appropriate course of antibiotic treatment pending culture results. See the NICE guideline on urinary tract infection (lower): antimicrobial prescribing for more information. [2006, amended 2019]

1.3.7.

If women have symptoms of UTI and their urine tests negative for either leucocytes or nitrites, send a midstream urine specimen for culture and analysis of antibiotic sensitivities. Consider the prescription of antibiotics pending culture results. [2006]

1.3.8.

If women do not have symptoms of UTI, but their urine tests positive for both leucocytes and nitrites, do not offer antibiotics without the results of midstream urine culture. [2006]

1.3.9.

If a woman does not have symptoms of UTI and her urine tests negative for either leucocytes or nitrites, do not send a urine sample for culture because she is unlikely to have UTI. [2006]

Assessing residual urine

1.3.10.

Measure post-void residual volume by bladder scan or catheterisation in women with symptoms suggestive of voiding dysfunction or recurrent UTI. [2006]

1.3.11.

Use a bladder scan in preference to catheterisation on the grounds of acceptability and lower incidence of adverse events. [2006]

Symptom scoring and quality-of-life assessment

1.3.12.

Use a validated urinary incontinence-specific symptom and quality-of-life questionnaire when therapies are being evaluated. [2006, amended 2019]

Bladder diaries

1.3.13.

Use bladder diaries in the initial assessment of women with urinary incontinence or overactive bladder. Encourage women to complete a minimum of 3 days of the diary covering variations in their usual activities, such as both working and leisure days. [2006]

Pad testin

1.3.14.

Do not use pad tests in the routine assessment of women with urinary incontinence. [2006]

Urodynamic testing

1.3.15.

Do not perform multichannel filling and voiding cystometry before primary surgery if stress urinary incontinence or stress-predominant mixed urinary incontinence is diagnosed based on a detailed clinical history and demonstrated stress urinary incontinence at examination. [2019]

1.3.16.

After undertaking a detailed clinical history and examination, perform multichannel filling and voiding cystometry before surgery for stress urinary incontinence in women who have any of the following:

• urge-predominant mixed urinary incontinence or urinary incontinence in which the type is unclear
• symptoms suggestive of voiding dysfunction
• anterior or apical prolapse
• a history of previous surgery for stress urinary incontinence. [2019]

Other tests of urethral competence

1.3.17.

Do not use the Q-tip, Bonney, Marshall and Fluid-Bridge tests in the assessment of women with urinary incontinence. [2006]

Cystoscopy

1.3.18.

Do not use cystoscopy in the initial assessment of women with urinary incontinence alone. [2006]

Imaging

1.3.19.

Do not use imaging (MRI, CT, X-ray) for the routine assessment of women with urinary incontinence. Do not use ultrasound other than for the assessment of residual urine volume. [2006]

Indications for referral to a specialist service

1.3.20.

In women with urinary incontinence, indications for consideration for referral to a specialist service include:

• persisting bladder or urethral pain
• palpable bladder on bimanual or abdominal examination after voiding
• clinically benign pelvic masses
• associated faecal incontinence
• suspected neurological disease
• symptoms of voiding difficulty
• suspected urogenital fistulae
• previous continence surgery
• previous pelvic cancer surgery
• previous pelvic radiation therapy. [2006]

1.3.21.

Follow the recommendations on referral for urinary tract cancer in the NICE guideline on suspected cancer, for women with haematuria or recurrent or persistent unexplained UTI. [2006, amended 2019]

Lifestyle interventions

1.4.1.

Recommend a trial of caffeine reduction to women with overactive bladder. [2006]

1.4.2.

Consider advising women with urinary incontinence or overactive bladder and a high or low fluid intake to modify their fluid intake. [2006]

1.4.3.

Advise women with urinary incontinence or overactive bladder who have a BMI greater than 30 to lose weight. [2006]

Physical therapies

Behaviourvioural therapies

1.4.11.

Offer bladder training lasting for a minimum of 6 weeks as first-line treatment to women with urgency or mixed urinary incontinence. [2006]

1.4.12.

If women do not achieve satisfactory benefit from bladder training programmes, the combination of an overactive bladder medicine with bladder training should be considered if frequency is a troublesome symptom. [2006]

Neurostimulation

1.4.13.

Do not offer transcutaneous sacral nerve stimulation (surface electrodes placed above the sacrum, often known as transcutaneous electrical nerve stimulation [TENS]) to treat overactive bladder in women. [2013]

1.4.14.

Do not offer transcutaneous posterior tibial nerve stimulation for overactive bladder. [2013]

1.4.15.

Do not offer percutaneous posterior tibial nerve stimulation (needles inserted close to the posterior tibial nerve) for overactive bladder unless:

• there has been a local MDT review and
• non-surgical management including overactive bladder medicine treatment has not worked adequately and
• the woman does not want botulinum toxin type A^[2] or percutaneous sacral nerve stimulation. [2013, amended 2019]

Absorbent containment products, urinals and toileting aids

1.4.16.

Do not offer absorbent containment products, hand-held urinals or toileting aids to treat urinary incontinence. Offer them only:

• as a coping strategy pending definitive treatment
• as an adjunct to ongoing therapy
• for long-term management of urinary incontinence only after treatment options have been explored. [2019]

1.4.17.

Offer a review at least once a year to women who are using absorbent containment products for long-term management of urinary incontinence. The review should cover:

• routine assessment of continence
• assessment of skin integrity
• changes to symptoms, comorbidities, lifestyle, mobility, medication, BMI, and social and environmental factors
• the suitability of alternative treatment options
• the efficacy of the absorbent containment product the woman is currently using and the quantities used. [2019]

1.4.18.

Reviews for women who are using absorbent containment products for long-term management of urinary incontinence should be carried out by either:

• a registered healthcare professional who is trained in assessing continence and making
• referrals to specialist services or
• a non-registered healthcare worker, under the supervision of a registered healthcare professional who is trained in assessing continence and making referrals to specialist services.

See indications for referral to a specialist service in this guideline. [2019]

Catheters

1.4.19.

Bladder catheterisation (intermittent or indwelling urethral or suprapubic) should be considered for women in whom persistent urinary retention is causing incontinence, symptomatic infections or renal dysfunction, and in whom this cannot otherwise be corrected. Healthcare professionals should be aware, and explain to women, that the use of indwelling catheters in urgency urinary incontinence may not result in continence. [2006]

1.4.20.

Offer intermittent urethral catheterisation to women with urinary retention who can be taught to self-catheterise or who have a carer who can perform the technique. [2006]

1.4.21.

Give careful consideration to the impact of long-term indwelling urethral catheterisation. Discuss the practicalities, benefits and risks with the woman or, if appropriate, her carer. Indications for the use of long-term indwelling urethral catheters for women with urinary incontinence include:

• chronic urinary retention in women who are unable to manage intermittent self-catheterisation
• skin wounds, pressure ulcers or irritations that are being contaminated by urine
• distress or disruption caused by bed and clothing changes
• where a woman expresses a preference for this form of management. [2006]

1.4.22.

Indwelling suprapubic catheters should be considered as an alternative to long-term urethral catheters. Be aware, and explain to women, that they may be associated with lower rates of symptomatic UTI, ‘bypassing’, and urethral complications than indwelling urethral catheters. [2006]

Products to prevent leakage

1.4.23.

Do not use intravaginal and intraurethral devices for the routine management of urinary incontinence in women. Do not advise women to consider such devices other than for occasional use when necessary to prevent leakage, for example during physical exercise. [2006]

Complementary therapies

1.4.24.

Do not recommend complementary therapies for the treatment of urinary incontinence or overactive bladder. [2006]

Medicines for overactive bladder

1.4.25.

Before starting treatment with a medicine for overactive bladder, explain to the woman:

• the likelihood of the medicine being successful
• the common adverse effects associated with the medicine
• that some adverse effects of anticholinergic medicines, such as dry mouth and constipation, may indicate that the medicine is starting to have an effect
• that she may not see substantial benefits until she has been taking the medicine for at least 4 weeks and that her symptoms may continue to improve over time
• that the long-term effects of anticholinergic medicines for overactive bladder on cognitive function are uncertain. [2019]

4.26.

When offering anticholinergic medicines to treat overactive bladder, take account of the woman’s:

• coexisting conditions (such as poor bladder emptying, cognitive impairment or dementia)
• current use of other medicines that affect total anticholinergic load
• risk of adverse effects, including cognitive impairment. [2019]

1.4.27.

For women who have a diagnosis of dementia and for whom anticholinergic medicines are an option, follow the recommendations on medicines that may cause cognitive impairment in the NICE guideline on dementia. [2019]

Invasive procedures for overactive bladder

1.4.43.

For women with overactive bladder that has not responded to non-surgical management or treatment with medicine and who wish to discuss further treatment options:

• offer urodynamic investigation to determine whether detrusor overactivity is causing her overactive bladder symptoms and
• if detrusor overactivity is causing her overactive bladder symptoms, offer an invasive procedure in line with recommendations 1.4.44 to 1.4.56 or
• if there is no detrusor overactivity, seek advice on further management from the local MDT in line with recommendation 1.4.45. [2013, amended 2019]

Botulinum toxin type A injection

1.4.44.

After a local MDT review, offer bladder wall injection with botulinum toxin type A^[4] to women with overactive bladder caused by detrusor overactivity that has not responded to non-surgical management, including pharmacological treatments. [2019]

1.4.45.

Consider treatment with botulinum toxin type A^[4] after a local MDT review for women with symptoms of overactive bladder in whom urodynamic investigation has not demonstrated detrusor overactivity, if the symptoms have not responded to non-surgical management and the woman does not wish to have other invasive treatments. [2019]

1.4.46.

After a local MDT review, discuss the benefits and risks of treatment with botulinum toxin type A^[4] with the woman and explain:

• the likelihood of complete or partial symptom relief
• the process of clean intermittent catheterisation, the risks, and how long it might need to be continued
• the risk of adverse effects, including an increased risk of urinary tract infection
• that there is not much evidence about how long the injections work for, how well they work in the long term and their long-term risks. [2019]

1.4.47.

Start treatment with botulinum toxin type A^[4] only if the woman is willing, in the event of developing significant voiding dysfunction:

• to perform clean intermittent catheterisation on a regular basis for as long as needed
• or
• to accept a temporary indwelling catheter if she is unable to perform clean intermittent catheterisation. [2013, amended 2019]

1.4.48.

Use 100 units as the initial dose of botulinum toxin type A^[4] to treat overactive bladder in women. [2019]

1.4.49.

Offer a face-to-face or telephone review within 12 weeks of the first treatment with botulinum toxin type A^[4] to assess the response to treatment and adverse effects, and:

• if there is good symptom relief, tell the woman how to self-refer for prompt specialist review if symptoms return, and offer repeat treatment as necessary
• if there is inadequate symptom relief, consider increasing subsequent doses of botulinum toxin type A to 200 units^[5] and review within 12 weeks
• if there was no effect, discuss with the local MDT. [2019]

1.4.50.

If symptom relief has been adequate after injection of 100 units of botulinum toxin type A^[4] but has lasted for less than 6 months, consider increasing subsequent doses of botulinum toxin type A to 200 units^[5] and review within 12 weeks. [2019]

1.4.51.

Do not offer botulinum toxin type B to women with overactive bladder. [2019]

Mid-urethral mesh sling procedures

1.5.7.

When offering a retropubic mid-urethral mesh sling, advise the woman that it is a permanent implant and complete removal might not be possible. [2019]

1.5.8.

If a retropubic mid-urethral mesh sling is inserted, give the woman written information about the implant, including its name, manufacturer, date of insertion, and the implanting surgeon’s name and contact details. [2019]

1.5.9.

When planning a retropubic mid-urethral mesh sling procedure, surgeons should:

• use a device manufactured from type 1 macroporous polypropylene mesh
• consider using a retropubic mid-urethral mesh sling coloured for high visibility, for ease of insertion and revision. [2013, amended 2019]

1.5.10.

Do not offer a transobturator approach unless there are specific clinical circumstances (for example, previous pelvic procedures) in which the retropubic approach should be avoided. [2019]

1.5.11.

Do not use the ‘top-down’ retropubic mid-urethral mesh sling approach or single-incision sub-urethral short mesh sling insertion except as part of a clinical trial. [2019]

Artificial urinary sphincters

1.5.12.

Do not offer women an artificial urinary sphincter to manage stress urinary incontinence unless previous surgery has failed. [2006, amended 2019]

1.5.13.

For women who have had an artificial urinary sphincter inserted:

• offer postoperative follow-up and
• ensure access to review if needed. [2006, amended 2019]

Procedures that should not be offered

1.5.14.

Do not offer women the following procedures to treat stress urinary incontinence:

• anterior colporrhaphy
• needle suspension
• paravaginal defect repair
• porcine dermis sling
• the Marshall–Marchetti–Krantz procedure. [2019]

Follow-up after surgery

1.5.15.

Offer a follow-up appointment within 6 months to all women who have had a surgical procedure to treat stress urinary incontinence. [2019]

1.5.16.

For women who have had retropubic mid-urethral mesh sling surgery, the follow-up appointment should include a vaginal examination to check for exposure or extrusion of the mesh sling. [2019]

1.5.17.

Providers should ensure that women who have had surgery for stress urinary incontinence have access to further referral if they have recurrent symptoms or suspected complications. See also assessing complications associated with mesh surgery in this guideline. [2019]

1.5.18.

For women whose primary surgical procedure for stress urinary incontinence has failed (including women whose symptoms have returned):

• seek advice on assessment and management from a regional MDT that deals with complex pelvic floor dysfunction or
• offer the woman advice about managing urinary symptoms if she does not wish to have another surgical procedure, and explain that she can ask for a referral if she changes her mind. [2019]

Lifestyle modification

1.7.2.

Consider giving advice on lifestyle to women with pelvic organ prolapse, including information on:

• losing weight, if the woman has a BMI greater than 30 kg/m²
• minimising heavy lifting
• preventing or treating constipation. [2019]

Topical oestrogen

1.7.3.

Consider vaginal oestrogen for women with pelvic organ prolapse and signs of vaginal atrophy. For recommendations on managing urogenital atrophy, see managing short-term menopausal symptoms in the NICE guideline on menopause. [2019]

1.7.4.

Consider an oestrogen-releasing ring for women with pelvic organ prolapse and signs of vaginal atrophy who have cognitive or physical impairments that might make vaginal oestrogen pessaries or creams difficult to use. [2019]

Pelvic floor muscle training

1.7.5.

Consider a programme of supervised pelvic floor muscle training for at least 16 weeks as a first option for women with symptomatic POP-Q (Pelvic Organ Prolapse Quantification) stage 1 or stage 2 pelvic organ prolapse. If the programme is beneficial, advise women to continue pelvic floor muscle training afterwards. [2019]

Pessaries

1.7.6.

Consider a vaginal pessary for women with symptomatic pelvic organ prolapse, alone or in conjunction with supervised pelvic floor muscle training. [2019]

1.7.7.

Refer women who have chosen a pessary to a urogynaecology service if pessary care is not available locally. [2019]

1.7.8.

Before starting pessary treatment:

• consider treating vaginal atrophy with topical oestrogen
• explain that more than 1 pessary fitting may be needed to find a suitable pessary
• discuss the effect of different types of pessary on sexual intercourse
• describe complications including vaginal discharge, bleeding, difficulty removing pessary and pessary expulsion
• explain that the pessary should be removed at least once every 6 months to prevent serious pessary complications. [2019]

1.7.9.

Offer women using pessaries an appointment in a pessary clinic every 6 months if they are at risk of complications, for example because of a physical or cognitive impairment that might make it difficult for them to manage their ongoing pessary care. [2019]

Surgery for uterine prolapse

1.8.8.

Discuss the options for treatment (see recommendation 1.8.2), including non-surgical options, hysterectomy and surgery that will preserve the uterus, with women who have uterine prolapse. [2019]

1.8.9.

For women considering surgery for uterine prolapse:

• discuss the possible complications and the lack of long-term evidence on the effectiveness of the procedures
• use the NICE patient decision aid on surgery for uterine prolapse to discuss the benefits and risks of treatment, including non-surgical options. [2019]

1.8.10.

For women with uterine prolapse who have no preference about preserving their uterus, offer a choice of:

• vaginal hysterectomy, with or without vaginal sacrospinous fixation with sutures or
• vaginal sacrospinous hysteropexy with sutures or
• Manchester repair.

  Also include the option of sacro-hysteropexy with mesh (abdominal or laparoscopic) in this choice but see recommendation 1.8.6 for specific guidance on the use of mesh in prolapse surgery. [2019]

1.8.11.

For women with uterine prolapse who wish to preserve their uterus, offer a choice of:

• vaginal sacrospinous hysteropexy with sutures or
• Manchester repair, unless the woman may wish to have children in the future.
• Also include the option of sacro-hysteropexy with mesh (abdominal or laparoscopic) in this choice but see recommendation 1.8.6 for specific guidance on the use of mesh in prolapse surgery. [2019]

1.8.12.

If a synthetic polypropylene mesh is inserted, the details of the procedure and its subsequent short- and long-term outcomes must be collected in a national registry (see collecting data on surgery and surgical complications in this guideline). [2019]

1.8.13.

Ensure the proposed treatment is reviewed by a regional MDT (see recommendation 1.1.4) if the woman wishes to have children in the future. [2019]

Surgery for vault prolapse

1.8.14.

Discuss the options for treatment (see recommendation 1.8.2), including non-surgical and surgical options, with women who have vault prolapse. [2019]

1.8.15.

For women considering surgery for vault prolapse:

• discuss the possible complications and the lack of long-term evidence on the effectiveness of the procedures
• use the NICE patient decision aid on surgery for vaginal vault prolapse to discuss the benefits and risks of treatment, including non-surgical options. [2019]

1.8.16.

Offer women with vault prolapse a choice of:

• vaginal sacrospinous fixation with sutures or
• sacrocolpopexy (abdominal or laparoscopic) with mesh.

  See recommendation 1.8.6 for specific guidance on the use of mesh in prolapse surgery. [2019]

1.8.17.

If a synthetic polypropylene mesh is inserted, the details of the procedure and its subsequent short- and long-term outcomes must be collected in a national registry (see collecting data on surgery and surgical complications in this guideline). [2019]

Colpocleisis for vault or uterine prolapse

1.8.18.

Consider colpocleisis for women with vault or uterine prolapse who do not intend to have penetrative vaginal sex and who have a physical condition that may put them at increased risk of operative and postoperative complications. [2019]

Surgery for anterior prolapse

1.8.19.

Discuss the options for treatment (see recommendation 1.8.2), including non-surgical and surgical options, with women who have anterior prolapse. [2019]

1.8.20.

Offer anterior repair without mesh to women with anterior vaginal wall prolapse. [2019]

1.8.21.

Recommendation withdrawn in June 2019.

1.8.22.

Recommendation withdrawn in June 2019.

Surgery for posterior prolapse

1.8.23.

Offer posterior vaginal repair without mesh to women with a posterior vaginal wall prolapse. [2019]

Follow-up after surgery

1.8.24.

Offer women a review 6 months after surgery for pelvic organ prolapse. Ensure that the review includes a vaginal examination and, if mesh was used, check for mesh exposure. [2019]

1.8.25.

Providers should ensure that women who have had surgery for pelvic organ prolapse have access to further referral if they have recurrent symptoms or suspected complications. See also assessing complications associated with mesh surgery in this guideline. [2019]

General considerations before removing mesh

1.11.1.

If a woman who has had a mesh procedure to treat urinary incontinence or pelvic organ prolapse is thinking about having the mesh removed, discuss the decision with her and with a regional MDT. [2019]

1.11.2.

When discussing surgery to remove mesh, explain to the woman that:

• there is limited evidence on the benefits of partial or complete removal compared with no mesh removal
• surgery to remove mesh can have significant complications including organ injury, worsening pain, and urinary, bowel and sexual dysfunction
• it is not certain that removing the mesh will relieve symptoms
• it might not be possible to remove all of the mesh
• removing only part of the mesh might be just as effective at improving symptoms as removing all of it
• urinary incontinence or prolapse can recur after the mesh has been removed.[2019]

Managing vaginal complications

1.11.3.

Discuss non-surgical treatment with topical oestrogen cream with women who have a single area of vaginal mesh exposure that is smaller than 1 cm². [2019]

1.11.4.

Offer a follow-up appointment within 3 months to women with vaginal mesh exposure who choose treatment with topical oestrogen cream. [2019]

1.11.5.

Consider partial or complete surgical removal of the vaginal portion of mesh for women:

• who do not wish to have treatment with topical oestrogen or
• if the area of vaginal mesh sling exposure is 1 cm² or larger or
• if there is vaginal mesh extrusion or
• if there has been no response to non-surgical treatment after a period of 3 months. [2019]

1.11.6.

Offer imaging and further treatment to women who have signs of infection in addition to vaginal mesh exposure or extrusion. [2019]

1.11.7.

Discuss with women who have vaginal complications after mesh sling surgery for stress urinary incontinence that:

• complete removal of the vaginal portion of mesh sling is associated with a greater risk of recurrence of stress urinary incontinence than partial removal
• partial removal is associated with a higher rate of further mesh sling extrusion
• complete removal might not be possible. [2019]

1.11.8.

Explain to women who have vaginal complications after vaginally placed mesh for pelvic organ prolapse that:

• complete removal might not be possible
• complete removal has a higher risk of urinary tract or bowel injury than partial removal
• there may be a risk of recurrent prolapse. [2019]

1.11.9.

Explain to women who have vaginal complications after abdominally placed mesh for pelvic organ prolapse that:

• removal is associated with a risk of urinary tract and bowel injury
• there is a risk of recurrent prolapse
• they might need abdominal surgery to remove the mesh
• complete removal might not be possible. [2019]

1.11.10.

For women who have pain or painful sexual intercourse suspected to be related to previous mesh surgery:

• if specialist assessment indicates a mesh-related complication, seek advice from a regional MDT
• if assessment and investigation do not show a mesh abnormality such as vaginal extrusion or exposure, or an infection, consider non-surgical treatments such as pain management, vaginal oestrogen, dilators, counselling (including psychosexual counselling) and physiotherapy
• if pain does not respond to initial management, seek advice from a regional MDT. [2019]

Managing urinary complications

1.11.11.

Refer women who have mesh perforating the lower urinary tract to a centre for mesh complications for further assessment or management. [2019]

1.11.12.

For women with urinary symptoms after mesh surgery for stress urinary incontinence or pelvic organ prolapse who are considering mesh removal surgery, explain that:

• urinary symptoms might not improve and new symptoms might occur after complete or partial removal of the mesh
• stress urinary incontinence might recur after mesh removal, and the risk of this happening is higher with complete than with partial mesh removal
• complete removal of the mesh might not be possible
• further treatment might be needed for mesh complications, or recurrent or persistent urinary symptoms
• there is a risk of adverse events such as urinary tract fistula. [2019]

1.11.13.

Discuss division of mesh sling with women who have voiding difficulty after mesh sling surgery. [2019]

1.11.14.

Refer women considering excision of mesh sling for persistent voiding dysfunction to a centre specialising in the diagnosis and management of mesh-related complications for assessment and management. [2019]

1.11.15.

For women considering surgery to alleviate voiding symptoms caused by mesh surgery, explain that:

• the risk of recurrent stress urinary incontinence is higher after mesh excision than mesh division
• further surgery might be needed. [2019]

Managing bowel symptoms

1.11.16.

For women who present with functional bowel disorders after mesh surgery for pelvic organ prolapse, follow the recommendations in the NICE guideline on faecal incontinence in adults for women with faecal incontinence or locally agreed protocols for women with obstructed defecation. [2019]

1.11.17.

For women with bowel complications that are directly related to mesh placement, such as erosion, stricture or fistula, discuss treatment with a regional MDT that has expertise in complex pelvic floor dysfunction and mesh-related problems. Use this discussion to formulate an individualised treatment plan with the woman. [2019]

1.11.18.

Explain to women with bowel complications directly related to mesh placement that:

• complete removal might not be possible
• bowel symptoms might persist or recur after mesh removal
• they might need a temporary or permanent stoma after mesh removal. [2019]

Anticholinergic medicine

A type of medicine used to treat overactive bladder. It reduces the activity of the bladder muscle by blocking chemical messengers to the nerves that control muscle movements.

Augmentation cystoplasty

A procedure to treat overactive bladder. The bladder is made larger by adding a piece of tissue from the intestines to the bladder wall.

Autologous rectus fascial sling

A type of sling used to treat stress urinary incontinence. It is made out of tissue from the woman’s abdomen. The sling supports the tube that carries urine out of the body (the urethra).

Botulinum toxin type A

A treatment used for overactive bladder. It is injected into the wall of the bladder.

Colpocleisis

An operation to treat pelvic organ prolapse by closing the vagina.

Colposuspension

A type of surgery used to treat stress urinary incontinence. The neck of the bladder is lifted up and stitched in this position.

Detrusor overactivity

Involuntary bladder contractions seen during a cystometry test. They can be the cause of overactive bladder symptoms.

Intramural bulking agents

Materials used to treat stress urinary incontinence. They are injected into the sides of the tube that carries urine out of the body (the urethra). This helps it remain closed so that urine is less likely to leak out.

Manchester repair

An operation used to treat uterine prolapse. The neck of the womb (the cervix) is shortened. It involves shortening the cervix (neck of the womb) and supporting the womb in its natural position.

Mesh procedure

An operation to insert plastic mesh to support tissues. Mesh procedures are used to treat stress urinary incontinence and pelvic organ prolapse in women.

Percutaneous sacral nerve stimulation

A procedure used to treat overactive bladder. A device is implanted in the back to stimulate the nerves at the base of the spine. These nerves affect the bladder and surrounding muscles.

Percutaneous posterior tibial nerve stimulation

A procedure used to treat overactive bladder. A mild electric current is passed through a fine needle to stimulate a nerve in the leg. This nerve controls bladder function.

Retropubic mid-urethral mesh sling

A type of sling used to treat stress urinary incontinence. A strip of plastic is placed behind the tube that carries urine out of the body (the urethra) to support it in a sling.

Sacrocolpopexy

A type of surgery used to treat vaginal vault prolapse. Plastic mesh is used to attach the vagina to a bone at the bottom of the spine.

Sacro-hysteropexy

An operation to treat uterine prolapse. Plastic mesh is used to attach the womb (the uterus) to a bone at the bottom of the spine.

Urinary diversion

A type of surgery used to treat stress urinary incontinence. It causes urine to flow through an opening in the abdomen into an external bag, instead of into the bladder.

Vaginal sacrospinous fixation

A type of surgery used to treat vaginal vault or uterine prolapse. The top of the vagina is stitched to a ligament in the pelvis. It is done through a cut on the inside of the vagina.

Vaginal sacrospinous hysteropexy

An operation used to treat uterine prolapse. The cervix is stitched to a ligament in the pelvis. It is done through a cut on the inside of the vagina.

1. Anticholinergic medicines

What is the effectiveness and safety of anticholinergic medicines for overactive bladder in older women? [2019]

To find out why the committee made this research recommendation, see rationale and impact.

2. Colpocleisis compared with sacrospinous fixation for pelvic organ prolapse

What is the effectiveness of colpocleisis compared with sacrospinous fixation for pelvic organ prolapse in elderly women? [2019]

To find out why the committee made this research recommendation, see rationale and impact. [2019]

3. Assessing complications associated with mesh surgery

What is the effectiveness of ultrasound-guided visualisation compared with clinical assessment to identify complications after mesh surgery for stress urinary incontinence or pelvic organ prolapse in women? [2019]

To find out why the committee made this research recommendation, see rationale and impact.

4. Pessaries or surgery for pelvic organ prolapse

What are the long-term outcomes, including patient satisfaction, from the use of pessaries compared with surgery for pelvic organ prolapse in women? [2019]

To find out why the committee made this research recommendation, see rationale and impact.

5.

Long-term risks of surgery with and without mesh

What are the long-term risks of mesh surgery compared with non-mesh surgery for stress urinary incontinence and pelvic organ prolapse in women? [2019]

To find out why the committee made this research recommendation, see the rationale and impact sections on surgical management of stress urinary incontinence and surgical management of pelvic organ prolapse.

Long-term effectiveness of botulinum toxin type A for overactive bladder

What is the long-term effectiveness of bladder wall injection with botulinum toxin type A for overactive bladder in women? [2019]

Surgery for stress urinary incontinence and pelvic organ prolapse

What is the most effective surgical management for women with both stress urinary incontinence and pelvic organ prolapse, including the sequence of interventions? [2019]

Pain management after mesh surgery

What is the effectiveness of pain management for women who present with chronic pain 3 months after mesh surgery for stress urinary incontinence or pelvic organ prolapse? [2019]

Why the committee made the 2019 recommendations

The committee agreed, based on their experience, that women with stress urinary incontinence, overactive bladder or primary prolapse would benefit from the broad range of expertise provided by a local multidisciplinary team (MDT). They agreed that a local MDT working within a regional clinical network could refer women to other services within the network for treatments that are not available locally, thus providing a broader choice of treatments.

The committee thought that women with complications related to mesh surgery, or with complex pelvic floor problems, should have access to a specialist MDT working at the regional level. The regional MDT could provide expert assessment and ensure that women are offered all available treatment options.

The committee acknowledged that membership of local and regional MDTs needs to be flexible and will vary in line with local and regional arrangements.

How the recommendations might affect practice

The recommendations on the different levels of MDTs, their composition, and how they should work together might affect how local and regional MDTs are commissioned and how services are currently organised.

Full details of the evidence and the committee’s discussion are in evidence review F: effectiveness of multidisciplinary teams for the assessment and management of urinary incontinence or pelvic organ prolapse.

Return to recommendations

Why the committee made the 2019 recommendations

The committee were concerned about the lack of reliable evidence on adverse events after surgery for urinary incontinence and pelvic organ prolapse, especially those that occur 2 years or more after surgery. They were also aware of the widespread public concern about the use of synthetic mesh to treat these conditions in women. The wording of the recommendations reflects the committee’s strong support for the collection of data in a national registry of surgery for urinary incontinence and pelvic organ prolapse in women.

The committee agreed that it would be helpful to provide a broad indication of the types of information that should be included in the registry, rather than specifying this in detail. The data in the registry will be analysed in the future to provide more reliable evidence than is available currently on the use of the various procedures in England and Wales and their long-term effects. This could be used to inform future guidance. The recommendations support the findings of the Mesh Oversight Group Report on reporting procedures in a national database.

The committee also agreed to highlight the importance of obtaining consent from women to include their data in the registry, and giving women a copy of their own data.

How the recommendations might affect practice

The recommendations are likely to have an impact on healthcare professionals and providers who are not already doing this because additional time and resource will be needed to report data to the registry and because of the cost of maintaining the registry and analysing the data.

Full details of the evidence and the committee’s discussion are in evidence review E: surgical and physical management of stress urinary incontinence and evidence review I: surgical management of pelvic organ prolapse.

Return to recommendations

Why the committee made the 2019 recommendations

The evidence did not show any benefit from urodynamic testing to assess stress urinary incontinence or stress-predominant mixed urinary incontinence in women who have demonstrable stress urinary incontinence before primary surgery. The committee concluded that urodynamic testing is not necessary for most women in this situation.

However, based on their experience the committee agreed that urodynamic testing can be beneficial if the diagnosis is unclear or if the woman has symptoms of voiding dysfunction, anterior or apical prolapse, or a history of surgery for stress urinary incontinence.

How the recommendations might affect practice

The recommendations are likely to reduce variation in practice, which is largely caused by uncertainty about the clinical value of urodynamic testing before surgery. They are also expected to reduce the number of women having urodynamic testing before surgery, and avoid unnecessary use of a procedure that some women find unpleasant.

Full details of the evidence and the committee’s discussion are in evidence review A: urodynamic assessment prior to primary surgery for stress urinary incontinence.

Return to recommendations

Why the committee made the 2019 recommendation

Although there was some good evidence showing that surgery is more effective than pelvic floor muscle training to manage stress urinary incontinence, the committee also took into account the risks associated with surgery and the absence of side effects from pelvic floor muscle training. They noted that the 2006 guideline committee had recommended pelvic floor muscle training, and had looked at evidence on both stress urinary incontinence and mixed urinary incontinence. The 2019 committee looked at evidence on stress urinary incontinence alone. The evidence showed that pelvic floor muscle training is just as effective as surgery for around half of women with stress urinary incontinence. The committee therefore decided to retain the 2006 recommendation for pelvic floor muscle training as a first-line treatment for stress urinary incontinence.

How the recommendation might affect practice

The 2019 recommendation is unchanged from 2006 and so should not lead to changes in clinical practice in most services. However, there might still be services in which pelvic floor muscle training is not routinely offered, so the recommendation might lead to a change in practice in those areas.

Full details of the evidence and the committee’s discussion are in evidence review H: lifestyle and conservative management options for pelvic organ prolapse.

Return to recommendations

Why the committee made the 2019 recommendations

There was no evidence available on the use of absorbent containment products to manage urinary incontinence. In the committee’s experience, these products are often used for long-term management, with no review of their ongoing suitability or discussion of other possible management options. The committee were particularly concerned about the effect that long-term use of these products can have on skin integrity if urine absorption is not adequate, noting that breakdown of vulval skin is uncomfortable and distressing. They agreed that a review of absorbent containment products should be done at least once a year to ensure that problems are identified more promptly and management can be tailored to women’s changing clinical and lifestyle needs.

The committee noted that standard medical reviews often do not include absorbent containment product use, and therefore agreed that reviews of absorbent containment products should be conducted or overseen by a continence-trained healthcare professional. They thought this would ensure that reviews are consistent and thorough, and offer women a full range of management options, including referral to specialist services if needed.

How the recommendations might affect practice

The recommendations will result in an increase in reviews for women using absorbent containment products. This might reduce the overall use of these products and lead to more referrals for alternative treatment. Although short-term costs might rise, long-term costs can be expected to fall through reduction in the use of absorbent containment products.

Full details of the evidence and the committee’s discussion are in evidence review B: treatment options for women using absorbent containment products.

Return to recommendations

Why the committee made the 2019 recommendations

The committee noted that there is very little evidence about how anticholinergic medicines prescribed for overactive bladder affect cognitive function in women. They were aware that some anticholinergic medicines have been associated with dementia and Alzheimer’s disease. They also noted that large numbers of women are prescribed anticholinergic medicines, with some estimates suggesting that one-third of women aged over 65 have some degree of incontinence. Because the long-term effects of anticholinergic medicines are uncertain, the committee stressed the importance of a full discussion with the woman, taking account of the woman’s total anticholinergic load and carrying out regular reviews. They also decided to make a research recommendation on anticholinergic medicines to inform future guidance.

The effectiveness of anticholinergic and other medicines for overactive bladder was not reviewed in this guideline update.

How the recommendations might affect practice

The recommendations might raise awareness of the potential adverse effects of anticholinergic medicines, especially on cognitive function, and result in women being able to make better informed choices about managing their overactive bladder. The recommendations should also ensure that healthcare professionals regularly review women who remain on long-term medication.

Full details of the evidence and the committee’s discussion are in evidence review C: the risks to cognitive function for women taking anticholinergic drugs for overactive bladder.

Return to recommendations

Why the committee made the 2019 recommendations

The evidence on botulinum toxin type A injections for overactive bladder was limited, especially on the long-term effectiveness, dosage and frequency of injections, and the risks of adverse effects. The committee decided to make a research recommendation on the long-term effectiveness of botulinum toxin type A to inform future guidance.

The committee discussed starting doses and agreed that there was not enough evidence on the benefits and risks to recommend starting treatment with a higher dose than 100 units. The committee were aware from their own experience that there may be an increased risk of self-catheterisation with 200 units and that women usually wish to avoid this if possible. Although starting with the lower dose (100 units) may result in some women needing more injections, the committee agreed that there was not enough evidence to support starting at the higher dose.

Despite the limited evidence, the committee agreed that increasing the dose to 200 units might be effective for women who have not had a satisfactory response to 100 units. The committee also agreed that an increase in dose to 200 units should be considered for women who had a response to 100 units that lasted less than 6 months. These recommendations were based on the committee’s clinical experience.

The committee discussed follow-up in clinical practice. They noted that the 2013 guideline recommended follow-up at 6 months, or sooner if symptoms return. However, based on their experience, the committee agreed that 6 months might be too late for some women, and recommended a telephone call or a clinic appointment within 12 weeks of their first injection.

How the recommendations might affect practice

The recommendations are expected to reduce variation in practice by giving clear guidance on the initial dose of botulinum toxin A for treating women with idiopathic overactive bladder.

Changes in practice are unlikely because services are already in place to support botulinum toxin type A treatment. There will be a cost saving by having a starting dose of 100 units. There may also be savings because the recommendations no longer specify that women need training in self-catheterisation before treatment.

Full details of the evidence and the committee’s discussion are in evidence review D: management of overactive bladder.

Return to recommendations

Why the committee made the 2019 recommendations

The evidence showed that there were no important differences in the short- and medium-term effectiveness of colposuspension, retropubic mid-urethral mesh slings and autologous rectus fascial slings, so the committee agreed that women should be offered a choice of these 3 procedures.

However, they emphasised that there is substantial uncertainty about the long-term complications associated with each procedure, and agreed that women should be made aware of this when choosing a procedure. They also made a research recommendation to help inform future guidance.

The committee acknowledged the public concern about the risks of these procedures, especially those involving the insertion of mesh products. However, they agreed that women should not be denied effective surgical options. Instead, women should be fully informed and supported by their doctor to make the right decision about their treatment, taking into account the benefits and risks of all the options as well as any individual social or psychological factors that might affect their decision. The committee agreed that a patient decision aid could help women better understand the different surgical options and promote shared decision making.

The committee also noted variation in the amount of information and level of detail given to women before surgery and agreed that key information should be included in the recommendations, with more detailed information provided in the patient decision aid. The committee noted the importance of giving women full information about the benefits and risks of these procedures.

How the recommendations might affect practice

More thorough and detailed discussion with women before they have surgery for stress urinary incontinence is likely to moderately increase the time spent in consultations.

Synthetic mesh slings, colposuspension, autologous rectus fascial slings and intramural bulking agents are offered in current practice. However, all surgical options are not available at every hospital and women may require referral to another centre (regional centre) if they choose to have a procedure that is not available locally. Regional centres may require extra resources to meet this need. There might also be an increase in the number of colposuspensions and autologous rectus fascial sling procedures carried out.

Full details of the evidence and the committee’s discussion are in evidence review E: surgical and physical management of stress urinary incontinence.

Return to recommendations

Why the committee made the 2019 recommendations

The evidence indicated that self-reported symptoms can accurately identify pelvic organ prolapse, although the committee noted that prolapse is often an incidental finding. They agreed, based on the evidence and their clinical experience, that accurate assessment of suspected pelvic organ prolapse depends on a thorough clinical history and examination.

The committee thought that secondary care clinicians who suspect or identify vaginal prolapse could consider referral to a clinician with expertise in prolapse.

Evidence showed that the POP-Q (Pelvic Organ Prolapse Quantification) system produces an accurate assessment of pelvic organ prolapse, and the committee agreed that it provides an objective and standardised measure that will ensure consistency of assessment.

Based on their experience, the committee agreed that it is important to assess pelvic floor muscles and vaginal atrophy, and to rule out a pelvic mass or other pathology. They also agreed that a validated pelvic floor symptom questionnaire could aid assessment.

The committee noted evidence showing that imaging does not provide any additional benefit in the assessment of vaginal prolapse diagnosed by physical examination. They agreed that imaging would delay management, and should not be routinely carried out in this situation.

Based on their experience, the committee agreed that symptoms of pelvic floor prolapse can become more prominent when the woman is straining or changes her position. They concluded that repeating the physical examination with the woman in a different position could be helpful if her symptoms are not explained by the physical examination. They also agreed, based on their experience, that other pelvic floor symptoms, including symptoms that remain unexplained after physical examination, should also be investigated.

How the recommendations might affect practice

The recommendations reflect current good practice, so the committee agreed there should be little change in practice.

Full details of the evidence and the committee’s discussion are in evidence review G: assessing pelvic organ prolapse.

Return to recommendations

Why the committee made the 2019 recommendations

Based on their experience, the committee agreed that there should be an initial discussion of the management options with women who have pelvic organ prolapse, including no treatment, non-surgical treatment and all surgical options.

How the recommendations might affect practice

Why the committee made the 2019 recommendations

How the recommendations might affect practice

More thorough and detailed discussion with women before they have surgery for pelvic organ prolapse is likely to moderately increase time spent in consultations. Sacro-hysteropexy with mesh is not available at all centres so this might increase referrals between centres. However, because fewer women are choosing mesh surgery, the increase in this type of referral is likely to be negligible. Similarly, there could be a small increase in referrals for laparoscopic sacrocolpopexy and colpocleisis, but this is not expected to have a significant impact on practice.

Full details of the evidence and the committee’s discussion are in evidence review I: surgical management of pelvic organ prolapse.

Return to recommendations

Why the committee made the 2019 recommendations

The evidence did not show any clear benefits for concurrent surgery for stress urinary incontinence and pelvic organ prolapse, but the committee agreed that it should be considered in women with anterior and/or apical prolapse and stress urinary incontinence. They agreed that women should be told about the uncertainty of the benefits and risks of concurrent surgery compared with sequential surgery, to ensure that they are equipped to make an informed decision. The committee made a research recommendation on the most effective surgical management for women with both stress urinary incontinence and pelvic organ prolapse.

How the recommendations might affect practice

The committee expect these recommendations to reduce variations in care and improve the information women are given when choosing between sequential and concurrent surgery for stress urinary incontinence and pelvic organ prolapse.

Full details of the evidence and the committee’s discussion are in evidence review J: surgical management of pelvic organ prolapse and stress urinary incontinence.

Return to recommendations

Why the committee made the 2019 recommendations

The committee noted, based on their experience, that there can be delays in the diagnosis of mesh-related complications. They therefore highlighted the importance of considering mesh as a possible cause of pain, vaginal problems, or urinary or bowel problems in women who have had mesh inserted.

The committee were unable to make generalised recommendations on assessing possible mesh-related complications because of the wide variety of procedures and implanted materials used, and the many different complications that might result from these. They therefore agreed that women with suspected mesh-related complications should be referred to a specialist centre unless they have an uncomplicated, small mesh exposure that can be treated with topical oestrogen.

There was little evidence available on the use of specific investigations to assess suspected mesh-related complications, so the committee decided to outline a range of possible investigations. They also made a research recommendation to inform future guidance.

How the recommendations might affect practice

The recommendations reflect current good practice and the committee did not expect them to result in changes in practice.

Full details of the evidence and the committee’s discussion are in evidence review K: assessing mesh complications after pelvic floor mesh surgery.

Return to recommendations

Why the committee made the 2019 recommendations

The available evidence was very limited and so the committee made recommendations based on their experience. They noted that women often have multiple complications from mesh surgery and that these complications can be long lasting. They also noted that the success of mesh removal varies widely depending on the specific mesh-related complication. In addition, some women who have complete mesh removal will have further complications and recurrence of stress urinary incontinence, pelvic organ prolapse, or both. The committee therefore agreed that healthcare professionals should have a full discussion with women who are considering having partial or complete mesh removal. They also agreed that mesh should be removed only after a review by the regional MDT.

Based on their experience, the committee agreed that topical oestrogen is only likely to be effective for small exposures of mesh and should be discussed with the woman as an option that could be tried before surgery is considered. They noted that some women who present with mesh exposure or extrusion with vaginal discharge may have a mesh infection, and imaging should be considered to assist in the diagnosis.

The committee acknowledged the impact that mesh perforation in the lower urinary tract has on women’s quality of life, and agreed that women with this complication should be referred for further assessment. Similarly, women who have pain or painful sexual intercourse should be offered specialist assessment. The committee reiterated the need to tell women about the possible benefits and risks of mesh removal surgery. The committee also noted the lack of evidence in this area and made a recommendation for research on pain management after mesh surgery.

How the recommendations might affect practice

The committee thought that these recommendations will reduce delays in treatment for mesh-related complications, although they might increase the number of referrals.

Full details of the evidence and the committee’s discussion are in evidence review L: management of mesh complications.

Return to recommendations